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Provider Data Management for Medicare Advantage and Medicaid Plans

Meet 90-day verification requirements, protect Star Ratings, and stay audit-ready across every federal and state program you operate. 

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Provider Data Management for <span>Medicare Advantage and Medicaid Plans</span>

Why Medicare and Medicaid Plans Face the Highest Stakes in Provider Data Management

For Medicare Advantage and Medicaid managed care plans, provider data inaccuracy is a revenue problem, a compliance problem, and a reputational problem simultaneously. CMS mandates directory verification every 90 days and updates within two business days. The REAL Health Providers Act adds mandatory public accuracy scoring from plan year 2029. Inaccurate directories directly affect Star Ratings, risk adjustment scores, and network adequacy findings, each with direct financial consequences. 

PRIME® delivers:

Automated 90-day verification cycles aligned to CMS and REAL Act requirements

Continuous monitoring between cycles for demographics and credentialing data

Audit-ready documentation for CMS submissions, state oversight, and Star Ratings support

Provider Data Inaccuracy Has Direct Financial and Regulatory Consequences

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The REAL Act Changes What Accuracy Means

Beginning plan year 2029, CMS publishes your directory accuracy score. Every broker, member, and state regulator will see it. Plans that start building continuous verification infrastructure in 2028 will not have enough time.  

Star Ratings Exposure Is Measurable and Compounding

Inaccurate directories create member access failures that reduce CAHPS scores and network adequacy ratings. For Medicare Advantage plans, each Stars decline costs millions in quality bonus payments.  

Ghost Network Liability Under the No Surprises Act

When a member relies on an inaccurate directory listing and goes out-of-network, the plan absorbs the cost-sharing difference. Every wrong listing is a direct claims liability. 

How PRIME® Addresses Provider Data Challenges for Medicare and Medicaid Plans

Data Validation

Meet the 90-Day Verification Standard the REAL Act Requires

PRIME® runs every provider record through a six-layer verification cycle aligned to the 90-day standard. Every step is logged, sourced, and timestamped, producing the documentation your annual accuracy analysis submission requires. 

Continuous Compliance Monitoring

Monitor Between Cycles to Catch What Scheduled Verification Misses

Scheduled verification tells you what was accurate at the last cycle. Continuous monitoring tells you what changed the day after. PRIME® monitors provider demographics, license status, and sanctions in parallel, flagging changes before they create directory errors or Star Rating findings.  

Instant Roster Comparison

Govern Delegated Provider Data With Source-Level Traceability

PRIME® ingests delegated files in any format, normalizes and validates the data, and tags every record with its source. When an accuracy analysis flags an error, your team can trace it to the originating group and fix the upstream feed rather than patching the directory repeatedly.  

Regulatory Documentation

Manage Federal and State Requirements From One Platform

CMS requirements and state Medicaid program standards are tracked independently within the same platform, with jurisdiction-specific rules applied to each program. One platform, all programs, all jurisdictions.  

Regulatory Standards PRIME® Supports for Medicare and Medicaid Plans

Aligned with the evolving standards governing Medicare Advantage and Medicaid managed care networks.

  • CMS and Federal: REAL Health Providers Act 90-day verification and accuracy reporting, Medicare Advantage directory standards, No Surprises Act two-business-day update requirements, Medicaid managed care federal network adequacy standards

  • Quality and Accreditation: CMS Star Ratings network accuracy measures, NCQA credentialing standards, HEDIS data quality requirements, network adequacy documentation for CMS plan reviews

  • State Medicaid Programs: State-specific credentialing timelines, state department of insurance directory mandates, state Medicaid exclusion list screening, CHIP program provider participation documentation

Key PRIME® Capabilities for Medicare and Medicaid Plans

90-Day Verification Compliance:

Automated cycles aligned to the REAL Act standard with full audit documentation

Delegated Data Governance:

Source-tagged ingestion and reconciliation for all delegated provider groups 

Star Ratings Data Support: 

Accurate network records that feed directly into quality program performance

FAQs

What specifically does the REAL Health Providers Act require?

Medicare Advantage organizations must verify every provider record every 90 days, remove departed providers within five business days, submit an annual accuracy analysis to HHS from plan year 2028, and display their publicly reported accuracy score from plan year 2029. 

How does PRIME® help plans meet the 90-day standard at scale?

PRIME® automates the full six-layer verification cycle across your entire network on a schedule aligned to the 90-day requirement, with every step logged and sourced for the annual accuracy analysis submission. 

Does PRIME® handle both Medicare Advantage and Medicaid managed care from one platform?

Yes. Federal CMS requirements and state Medicaid standards are tracked independently within the same platform, with jurisdiction-specific rules applied to each program line. 

How does PRIME® address delegated credentialing as a source of directory inaccuracy?

PRIME® ingests delegated files in any format, normalizes the data, and tags every record with the originating delegated group. Directory errors trace back to their source so the upstream problem gets fixed, not just patched.